Reforming mental commitment statutes

"Because of the inadequacies of our current civil commitment practices, 5,000 individuals with mental illness commit suicide annually.[2] Another 200,000 are homeless.[3] Of course, those are not primary concerns to libertarians, most of whom believe that individuals have a right to kill themselves or live homeless.

But as a result of our current restrictive commitment procedures, persons with mental illness kill 1,000 individuals annually, roughly 10% of all homicides.[4] The most likely victims are family members,[5] police, and sheriffs.[6] ...

Because of restrictive civil commitment laws, individuals with serious mental illness are regularly shot by law enforcement who believe their erratic and irrational behavior is putting their own safety or that of the public in immediate danger.[7] People with severe mental illnesses are killed by police in justifiable homicides at a rate nearly four times greater than the general public."

I can remember back to the beginnings of the deinstitutionalization movement in the late 60s and early 70s. Back then, commitment was much more broadly allowed, but actual treatment (as in medications) was in its infancy. The result was that patients were "warehoused" unless and until they spontaneously became sane, which wasn't very likely. Today the prospects are quite different, hundreds of medications in the spectrum, and the main problem is getting a person to stay on the meds. But commitment has become so rare that people don't think of it as a possibility. The guy here who shot Rep. Giffords -- his college was so scared of him they banned him from coming there, and sent security guards to his home to notify him. But nobody thought of calling the police to take him to the psych ward for a check out.

As Clayton Cramer has pointed out, the seriously insane were largely moved from mental institutions to jail.

Forget about Wikipedia, my mom became an RN in the '50s and part of her residency was 3 months in a psych ward. Later, after finishing her specialization as a nurse anesthetist in the mid-late '50s she got a job in that same hospital and to her astonishment saw working in it, at a low level role like something janitorial, one of the "hopeless" cases she'd previously attended to.

These really were miracle drugs ... but not a complete solution. I'd add that for bipolar disorder, lithium chloride's narrow therapeutic index (hard to get the dose right, therapeutic level close to toxic) resulted in it not beingt approved by the FDA until 1970 according to Wikipedia ... but it was available then and by then we'd had almost two decades of experience with the typical antipsychotics and 1st generation antidepressants:

I don't know how many severely depressed kill others instead of just themselves, but per Wikipedia the first and rather dangerous generation of them had a "heyday [that] was mostly between the years 1957 and 1970", before being replaced by safer 2nd generation ones, and now we're in the quite safe 3rd generation that started with Prozac.

I would dispute that the 3rd generation drugs are "quite safe". I have friends who have gone psychotic on prescribed 3rd generation mental health meds (fortunately, they didn't hurt anyone and had someone close by to see what was going on and intervene and get them off said medications). Safer, maybe, but not "quite safe".

I mean "quite safe" in terms of non-psychological side effects; you may or may not know that giving anyone a psychotropic drug is never entirely safe, as your friends' experiences show.

I emphasized this in the discussion (which perhaps ought to have included mentioning of the side effects of first generation "typical" antipsychotics, but didn't because almost anything was superior to the alternative) because lithium carbonate's therapeutic index is so narrow it delayed by many years acceptance of the drug (two decades in the US), and because the first general of antidepressants were quite dangerous.

The MAOIs have many potentially lethal interactions with various foods and drugs. If you make a habit of reading the prescribing information for drugs you'll notice how many of them are contraindicated if the patient is on a MAOI, and some of these are over the counter (e.g. the dextromethorphan in cough suppressants). And then there are the foods one must not eat, anything tyramine rich, like aged cheese. I have a friend who was on one and she mentioned a hypertensive crisis that was caused by accidentally ingesting some at an event.

The second generation of tricyclic and the like antidepressants didn't have the above dangers, but they have strong antimuscarinic properties. Common side effects (per Wikipedia and confirmed by memory) include "dry mouth, dry nose, blurry vision, lowered gastrointestinal motility or constipation, urinary retention, cognitive and/or memory impairment, and increased body temperature." They basically change a bunch of the body's psychological "set points", like changing a thermostat. Another major one is poor regulation of blood pressure when a patient suddenly stands up, which can have strong effects all the way to short blackouts. They're a class of drugs that demand careful prescribing and followup the first time they're prescribed for a patient including e.g. before and after blood pressure testing.

(And as you may guess, I speak of the above from hard experience.)

By comparison the 3rd generation that started with Prozac are perhaps a little less effective than the tricyclics, but their side effect profiles are so much better than much less care is required and critically compliance is much less of a problem. Thing is, these drugs take weeks to show positive effects, and a lot of people, who of course were depressed, had difficultly waiting through that period when they were reaping nasty side effects without any therapeutic benefit.

But of course you're right they aren't 100% safe; a doctor of mine in 2004 prescribed Paxil, which had just gone generic ($$$ was an issue at the time) and that sent me straight to hypomania (mania without hallucinations), which he just didn't really appreciate until my GP alerted him to it. At which time he ordered me to keep a sleep log, which showed I was getting 3 30 minute periods of sleep a night (mania can be a medical emergency).

Fortunately I realized I was impaired and didn't do anything particularly stupid (well, besides reestablishing contact with my sister, but that's a different kind of "stupid", one is never happy about having to cut off a close relative because they're just too toxic), and then I got first hand experience of how utterly nasty atypical antipsychotics can be when my doctor switched me to Zyprexa for a while to stop the mania. I can well understand why a lot of schizophrenics don't want to take their meds and outside of an institutional setting just won't.